Resident Editors: Scott Goldberg, MD, Lekshmi Santhosh, MD

Faculty Editor: Ralph Gonzales, MD

Background

• Edema is fluid in the interstitial space that occurs when local or systemic conditions cause capillary filtration to exceed the limits of lymphatic drainage
• The pivotal branch point in the approach to lower extremity edema is whether it is bilateral or unilateral
  • Bilateral edema results from systemic causes such as new medications, cardiac, renal, or liver disease
  • Unilateral edema occurs due to venous insufficiency, DVT, lymphedema, or cellulitis

Causes of Unilateral Lower Extremity Edema

• Venous obstruction
  • Deep venous thrombosis
  • Lymphadenopathy or mass
• Lymphedema (secondary)
  • Neoplasm
  • Radiation
  • Post-surgical
  • Rare causes (filariasis, TB, recurrent lymphangitis)
• Localized edema
  • Cellulitis
  • Trauma
  • Burns
  • Ruptured Baker’s cyst

Causes of Bilateral Lower Extremity Edema: A Systems Approach

• Systemic Cause
  • Cardiovascular
    • Heart failure with either reduced or preserved ejection fraction
    • Pulmonary hypertension with RV failure
    • Constrictive pericarditis
  • Hepatic (cirrhosis)
  • Renal
    • Nephrotic syndrome
    • End-stage renal disease
  • GI
    • Nutritional deficiency or malabsorption leading to hypoalbuminemia
    • Protein-losing enteropathy
  • Medications
    • Calcium channel blockers (most commonly)
    • Thiazolidinediones (Rosiglitazone, pioglitazone)
  • Endocrine: myxedema
• Venous or Lymphatic cause
  • Venous
    • Obstruction: bilateral pelvic or retroperitoneal lymphadenopathy
    • Insufficiency
  • Lymphatic obstruction (bilateral)

Comprehensive History & Physical

Suspected Diagnosis	Deep Venous Thrombosis	Chronic Venous Insufficiency	Heart Failure	Lymphedema
History/ROS	H/o DVT or malignancy Recent immobilization Recent surgery Chest pain & dyspnea	Obesity Prolonged standing Sensation of leg heaviness Diabetes	Hypertension High-salt diet History of MI Diuretic adherence	H/o malignancy H/o recent surgery H/o travel to filariasis area
Physical Exam	Homan’s sign Unilateral edema Palpable cord Sinus tachycardia	Brawny hemosiderin Varicose veins Pitting edema +/- overlying erythema Atrophie blanche (rare) Shallow large ulcers, classically over medial malleolus	Jugular venous distention S3 and S4 heart sounds Hepatojugular reflux Ascites Hepatosplenomegaly	Unilateral edema Gross enlargement of extremity
Making the Diagnosis	D-dimer Ultrasound with Doppler	Duplex ultrasound	Echocardiogram	Clinical diagnosis based on history and ruling out other causes
Treatment	Anticoagulation therapy Compression stockings to prevent post-thrombotic syndrome	Compression stockings Skin care		Compression stockings with adjuvant pneumatic compression devices Skin care

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

• HPI: unilateral vs. bilateral, chronicity, pain, erythema, trauma, medications, aggravating/alleviating factors
•  ROS: systemic but focused on cardiac, liver, kidney disease, and malignancy related

•  Physical Exam
• General appearance: Pallor, BMI, ambulation, anasarca, temporal wasting
  • HEENT: periorbital edema, thyromegaly
  • CV: rate, rhythm, PMI, S3/S4, murmurs, JVD, RV heave
  • Pulm: dullness to percussion, crackles
  • GI: ascites, hepatomegaly
  • Lymph nodes: particularly axillary & inguinal
  • Skin: brawny legs, varicose veins, pitting vs. non-pitting, erythema, tenderness, warmth, stigmata of liver disease

Diagnostic Approach

• Unilateral Edema: Is it acute or chronic?
  • Acute (<72 hours)
    • What is your pre-test probability for DVT (based on the Wells score)?
      • Low à D-dimer
        • Normal à consider other etiologies (cellulitis, etc.)
        • Elevated à duplex ultrasonography
      • High à duplex ultrasonography
        • Positive à treat
        • Negative à consider other etiologies
  • Chronic
    • History of cancer, pelvic surgery, or trauma?
      • Yes à pelvic MR venography to look for tumor or thrombus obstruction
        • Positive à further treatment
        • Negative à does the exam suggest lymphedema?
          • Yes à confirm with diagnostic testing
          • No à consider other causes
      • No à duplex ultrasonography to look for chronic venous insufficiency
        • Suggestive of CVI à treat
        • Not suggestive à consider lymphedema and other causes
           
•  Bilateral edema or anasarca: Does the clinical exam and history suggest systemic disease?
  • Yes à systemic evaluation based on suspected etiology (cardiac, hepatic, renal): CBC, CMP, coags, UA, spot urine protein/creatinine ratio, TTE, abdominal ultrasound
  • No
    • Acute à likely medication-induced (stop the med)
    • Chronic à workup based on clinical examination for possible etiologies including chronic venous insufficiency, lymphedema, bilateral venous obstruction, etc.

References

Bergan, John J., et al. "Chronic venous disease." New England Journal of Medicine 355.5 (2006): 488-498.

DynaMed Plus [Internet]. Ipswich (MA): EBSCO Information Services. 1995 - . Record No. 920291, Edema - approach to the patient; [updated 2017 Oct 09, cited March 24, 2018].

Stern S, Cifu A, Altkorn D. (2015). Symptom to diagnosis : an evidence-based guide, third edition. New York :Lange Medical Books / McGraw-Hill, Medical Pub. Division,

Trayes, Kathryn, James S. Studdiford, Sarah Pickle, and Amber S. Tully. “Edema: Diagnosis and Management.” American Family Physician 88, no. 2 (July 15, 2013): 102–10.